Pubdate: Sept. 19, 1997 Source: Psychiatric News Page: 11 Contact: (202) 6826114 HeroinPrescribing Program in Switzerland Said to Improve Addicts' Health By Richard Karel More than five years after closure of the notorious "Needle Park" in Zurich, Switzerland The Swiss government has reported that an alternative, threeyear trial of controlled heroin prescribing for heroin addicts has been a resounding success. Five years ago the failure of a daring Swiss experiment that permitted an open air drug market in Zurich's Platzspitz park made headlines worldwide. That experiment collapsed of its own weight when the open, unregulated market attracted hordes of addicts and drug dealers from Europe and beyond. Television and newspaper stories featured nightmarish scenes of trampled shrubbery, urinesoaked soil littered with syringes, and zonked out junkies lying on park benches. Petty crime and overdoses soared. All this made for sensational news and elicited much head shaking as to what this implied for further attempts to deal with narcotics addiction in a medically oriented, non punitive way (Psychiatric News, September 1, 1993). Undaunted, the Swiss designed a structured protocol to see whether prescribing heroin under controlled conditions could work. The program was targeted to those with a history of heroin addiction who had not done well in prior treatment. The study focused on comparing injectable morphine, methadone, and heroin prescribed for supervised use. It found that recruitment, retention, and compliance were significantly better with injectable heroin than with morphine or methadone. Heroin caused fewer adverse side effects than the other drugs. The researchers found no absolute contraindications for prescribing heroin, although they noted that caution was necessary for patients with epilepsy. Heroin laced cigarettes were also tried but proved largely ineffective. Psychiatrist Ambros Uchtenhagen, M.D., director of the University of Zurich's Addiction Research Center, developed and guided the project. Although heroin was clearly the drug of choice for this target group, he still favors oral methadone for those willing to use it. Heroin "is not the medication of choice for maintenance,'' Uchtenhagen told Psychiatric News. "The advantages of oral methadone have been established a long time ago" and include oral administration, longer duration of action, and less euphoria. But heroin appears to be useful for those who cannot or will not take methadone. The results are not transferable to the United States or other countries that have yet to establish adequate methadone programs, Uchtenhagen said. "In any country where methadone maintenance is not sufficiently available, heroin maintenance is out of place." Both the physical and mental health of patients were said to have improved markedly over the program's duration. Depression, anxiety, and delusional disorders declined steadily. Pregnancies and births during the program were uneventful, with the exception of one miscarriage during heroin withdrawal. There were no signs of developmental defects in neonates. Illicit heroin and cocaine use dropped "rapidly and markedly'' during the program, the authors said. Benzodiazepine use, however; decreased very slowly, and alcohol and cannabis use remained virtually unchanged. A majority of patients continued regular during the first six months of treatment. Court convictions dropped sharply. The retention rate was 69 percent over 18 months and 89 percent for the first six months, well above average compared with other heroin treatment programs. An 18 month measure of retention was used, rather than a threeyear measure, said Uchtenhagen, because it was necessary to have a a sufficient number of participants, and there were not enough participants for whom the whole threeyear period would apply." Patients were admitted until June 1996, only six mouths before the of final trial ended, he noted. By the end of 1996, 83 people had decided to give up heroin and enter abstinencebased treatment. The longer people stayed in treatment, the greater was the probability they would choose abstinence. Improvements in the overall standard of living that occurred during treatment lasted at least six months after treatment ended. Although illicit drug use increased slightly after the program ended, It remained well below the initial level, as did contacts with the drug scene and illicit income. From the total of 1,146 enrollees, there were three new HIV infections, four hepatitis B infections, and five hepatitis C infections, which researchers believe were contracted by cocaine injection outside the program. Thirtysix participants died by the end of the program, including 17 deaths from AIDS and other infectious diseases. Several died from overdose of non prescribed drugs, and several by suicide and accidents. Within the study settings there were no fatal overdoses. The annual mortality rate of 1 percent was at the lower limit of what is known from other studies of treated heroin dependents and was markedly lower than that for untreated patients, the authors observed. No major disturbance was caused to local neighborhoods where clinics were sited. An analysis revealed an overall economic benefit per patient day of $144, with most of this based on savings in criminal investigations and incarcerations, followed by heath improvements. Researchers calculated that the program yielded a net economic benefit of $68 per patient day. The protocol for the program required that injections of prescribed narcotics be given under supervision and could not be taken home. The regimen provided help securing housing anti employment, treatment for somatic and psychiatric conditions, and counseling on developing a healthier life style. The provision of psychosocial care "was indispensable for the outcome," remarked Untenhagen. The many problems people bring to treatment cannot be changed by merely handing out medication, he said. There are advantages and disadvantages to r4equiring that heron be used on site, Uchtenhagen said. The advantages are safety and lack of diversion. The disadvantages include the costs of keeping clinics open every day and inconvenience to the addict. Although the program is considered a success, there is a constituency opposed to all forms of maintenance treatment, said Uchtenhagen. A national referendum is slated for this September: Should it pass, all forms of narcotics prescribing for addiction, including methadone would be stopped. "The negative consequences would be quite severe," said Uchtenhagen. "Any further planning [for maintenance programs] can start only after this referendum.''# The Swiss Federal Office of Public Health in Berne and the Addiction Research Institute in Zurich announced results of the heroinprescribing trial at a July 10 press conference in Berne. A summary of the results was provided to Psychiatric News by the Lindesmith Center, a New Yorkbased nonprofit organization that promotes alternatives to current drug policies. Within weeks of the report's release, the Australian government announced plans to launch a similar heroinprescribing trial, and the Dutch Health Minister said she favored a similar trial (see box above).* The experiment began January 1, 1994, and ended December 31, 1996. It involved a total of 18 sites in 12 cities, incIuding one prison. The program began with about 200 enrollees and grew to a total of 1,146, of whom 350 dropped out by the end of 1996. #The referendum was soundly defeated in September. * The Australian gov't first approved, then canceled, a limited heroin trial. It's still an issue since the underlying problem of skyrocketing overdose deaths continues unabated.